Care of Musculoskeletal Problems in the Outpatient Setting - part 2 ppt

● Water ● Sports drink ● Diluted fruit juices (2:1) water/juice After/Postexercise—sooner the better A. 30 to 60 min after exercise B. 240 to 400 cal. (60–100 g carbs) or 1/2 gram carbo per pound body weight (bagels, yogurt, fruits, juices, carbo load drinks, soft pretzels) C. Water—a minimum of 1 qt. (32 oz.) of H 2 O for each hour of intense exercise or for each pound wt. loss replace w/16 to 24 oz. H 2 O. 30 E. Trowers TABLE 3.1. High-calorie sample meal plan (approximately 6000 cal). Breakfast: 3/4 c. orange juice: 1 c. hot cereal with 2 tsp. sugar; 1 egg fried; 1 slice whole wheat toast with tsp. margarine, 1 tsp. jelly; 8 oz. milk (whole) Total cal. = 620 Snack: 1 peanut butter and jelly sandwich (2 slices bread, 2 Tbsp. peanut butter, 2 tsp. jelly); 1/2 c. raisins; 1 c. apple juice. Total cal. = 680 Lunch: 1 ham and cheese sandwich (2 slices bread, 1 oz. cheese, 1 oz. ham, 1 Tbsp. mayonnaise); 1 serving french fries; 1 c. tossed green salad with 2 Tbsp. dressing; 10-oz. chocolate milkshake; 4 oatmeal cookies Total cal. = 1440 Snack: 1 bagel with 2 tsp. margarine and 2 Tbsp. cream cheese; 1 c. sweetened applesauce; 3/4 c. grape juice Total cal. = 710 Dinner: 2 pieces baked chicken (7 oz. total); 1 c. rice with 1 tsp. margarine; 1 c. collard greens; 1/2 c. candied sweet potatoes; 2 pieces cornbread with 1 Tbsp. margarine; 8 oz. milk (whole); 1 slice apple pie Total cal. = 1760 Snack: 1 banana; 1/2 c. peanuts; 1 c. chocolate milk (whole) Total cal. = 720 c., cup; oz., ounce; tsp., teaspoon; cal., calories; Tbsp., tablespoon. TABLE 3.2. Sample pre-activity meals (to be eaten 3to 4 h prior to event). ● 3/4 c. orange juice; 1/2 c. cereal with 1 tsp. sugar; 1 slice whole-wheat toast with 1 tsp. margarine and 1 tsp. honey or jelly; 8 oz. skim or low-fat milk; water ● Total cal. = 450–500 ● 3/4 c. orange juice; 1 to 2 pancakes with: 1 tsp. margarine and 2 Tbsp. syrup: 8 oz. skim or low-fat milk; water ● Total cal. = 450–500 ● 1 c. vegetable soup; 1 turkey sandwich with 2 slices bread, 2 oz. turkey (white or dark), 1-oz. cheese slice, 2 tsp. mayonnaise; 8 oz. skim or low-fat milk ● Total cal. = 550–600 ● 1 c. spaghetti with tomato sauce and cheese; 1/2 c. sliced pears (canned) on 1/4 c. cottage cheese; 1 to 2 slices Italian bread with 1 tsp. margarine (avoid garlic); 1/2 c. sherbet; 1 to 2 sugar cookies;4 oz. skim or low-fat milk; water ● Total cal. = 700 2. Consequences of Unhealthy Eating Obesity is defined as a state of excess adipose tissue mass. The most widely used method to gauge obesity is the body mass index (BMI), which is equal to weight/height 2 (in kg/m 2 ). BMIs for the midpoint of all heights and frames among both men and women range from 19 to 26 kg/m 2. Based on unequiv- ocal data of substantial morbidity, an individual with a BMI greater than 25 is overweight and of 30 is obese in both men and women. Large-scale epi- demiologic studies suggest that all-cause, metabolic, cancer, and cardiovascular morbidity begin to rise when BMIs are greater than or equal to 25. There are multiple possible causes for obesity, which include heredity and increased caloric intake versus low energy expenditure. We cannot choose our ancestors but we can control what we eat and how and how much we exercise. A number of pathophysiologic consequences result from obesity including insulin resistance and type 2 diabetes mellitus. Either one of these conditions can result in increased atherosclerotic cardiovascular and peripheral vascular disease, which is the basic etiology of heart attacks and strokes. Just think of it, one could possibly avert or greatly minimize the possible seriously debili- tating consequences of top two major health problems in the United States simply by eating a balanced diet and exercising on a regular basis. Obesity is associated with other disabling reproductive disorders such as hypogonadism in males. In women, obesity may be associated with irregular menses and amenorrhea. Obesity-induced hypertension is associated with increased peripheral resistance and cardiac output, increased sympathetic nervous tone, and increased salt sensitivity. Obesity may be associated with pulmonary abnormalities such as increased work of breathing, decreased total lung capacity, and obstructive sleep apnea. Sleep apnea can greatly impede an active lifestyle. Sleep apnea may preclude patients from driving, operating heavy machinery, or employment that requires constant alertness. Simple tasks such as staying awake during class or everyday conversation or activities may be significantly compromised. Gallstone disease is associated with obesity. Since gallstone-related surgery is one of the most common surgeries in the United States, a healthy lifestyle might contribute to a reduction of this problem developing. Obesity is also associated with a higher death rate from cancer of the esophagus, pancreas, liver, colon, rectum, and prostate in men. Women who are obese are at greater risk of death from cancer of the breasts, endometrium, cervix, ovaries, gall- bladder, and bile ducts. Bone and joint problems, problems such as osteoarthritis, and gout occur more frequently in obese individuals. Skin abnormalities like acanthosis nigri- cans (darkening and thickening of the skin) occur more frequently in the obese. Stretch marks and thinning of the skin also occur more often in obese persons. The approach to helping the obese patient involves a several-pronged attack plan. First, behavior modification is an important first step. Unless 3. Nutrition for Active People 31 patients recognize that a problem exists and are committed to solving the problem, very little can be achieved. Certain techniques that are beyond the scope of this text can be employed to successfully reorient the obese persons’ thinking about themselves, dietary habits, and exercise program. Concerning weight reduction and obesity, gradual versus rapid approach is preferred. Monitoring by a qualified health care professional and/or dietician can help enhance compliance and minimize the development of complications seen with a rapid reduction of calories and fluids. Unsafe practices such as ene- mas, induced vomiting, starvation, laxatives, diuretics, steam rooms, and over-the-counter appetite suppressants should be avoided. Weight loss should occur gradually at approximately 1 to 2 lb per week while the patient consumes well-balanced meals and undergoes a tailored exercise program that has been cleared by the physician. 3. Childhood Obesity Obesity is an increasing problem in children and adolescents. From 1974 to 2000 the number of obese children increased from 3% to 12%. Obesity in children is defined as 95% of expected BMI for age. Overweight is defined as greater than 85% of expected BMI. BMI tables and graphs for all ages are available at www.cdc.gov. Once in the Web site, place the word “BMI” in the search engine to find excellent information on BMI. Suggested programs for nutrition and physical activity can also be obtained on the Internet. Three such programs and their Web sites are as follows: 1. TAKE 10 (www.take10.net) is a classroom-based physical activity program for kindergarten to fifth-grade students. It contains a curriculum tool for teachers and students, safe and age-appropriate 10-min physical activities, and fun characters that represent organs of the body (The OrganWise Guys). 2. SPARK (www.sparkpe.org) has organized curriculum for teaching children about nutrition and healthy food choices, safety and injury prevention, positive self-talk, goal setting, and balance and moderation in diet and exercise. 3. The National Center for Chronic Disease Prevention and Health Promotion program “Healthy Youth” (http://www.cdc.gov/healthyyouth/index.htm) has sections on healthy eating and physical activity as well as other healthy behaviors in children. 4. Weight Control Issues for Teens Gymnasts, wrestlers, and endurance athletes, e.g., lightweight rowers, are generally concerned about making their weight classification for competition. Because of increasing pressure to win, these young athletes may engage in 32 E. Trowers various activities to loose weight. Anorexia nervosa, bulimia, starvation diets, fad diets, purging, fluid restriction, laxative ingestion, and improper consumption of stimulants may expose these individuals to possible serious health problems. Proper caloric intake, fluid consumption, nutritional educa- tion, and prescribed exercise routines can go a long way in preventing the pre- viously mentioned disorder. Today’s athletes are bigger, stronger, and faster than their predecessors. Some teens may try to gain weight by eating large quantities of fatty and other non- nutritious foods. The main goal of weight gain in the athlete is to increase muscle mass. This is best achieved by an increase in muscle building workout routines and increased caloric intake. Despite the claims of some health food companies there are no special substances that can cause one to magically gain weight. The goal should be to consume a balanced diet and gain approximately 1 to 2 lb per week. This can be accomplished if the average teen consumes an additional 500 to 1000 cal per day. In general, if an athlete gains weight at a faster clip than as mentioned, the increased weight will be in the form of fat as opposed to muscle. See Tables 3.3 and 3.4 for sample meal plans for losing weight and increasing caloric intake via high carbohydrate meals. 3. Nutrition for Active People 33 TABLE 3.3. Sample meal plan for losing weight. 1800 cal: Breakfast: 3/4 c. orange juice; 3/4 c. cereal; 8 oz. low-fat milk; 1 slice whole-wheat toast with 1 tsp. margarine Total cal. = 415 Snack: 1 apple Total cal. = 80 Lunch: 1 peanut butter and banana sandwich (2 slices bread, 1 Tbsp. peanut butter, 1/2 banana); 5 to 7 carrot sticks; 1 peach; 8 oz. low-fat milk Total cal. = 485 Snack: 20 grapes; 2 graham crackers Total cal. = 155 Dinner: 1 hamburger patty (4 oz.) with 1 hamburger bun; 1 c. tossed green salad with 1 Tbsp. dressing; 4 oz. low-fat milk; 1/2 c. ice cream Total cal. = 715 2400 cal: Breakfast: 3/4 c. orange juice; 1 slice toast with 1 oz. cheese; 3/4 c. cereal; 4 oz. low-fat milk Total cal. = 420 Snack: 1 banana Total cal. = 100 Lunch: 1 slice cheese pizza; 1 cup tossed green salad with 1 Tbsp. dressing; 8 oz. low-fat milk Total cal. = 425 Snack: 1/2 c. raisin/peanut mix; 1/2 c. apple juice Total cal. = 360 Dinner: 1 c. macaroni and cheese; 1/2 c. lima beans; 1 c. tomato and cucumber slices with 1 Tbsp. dressing; 1 dinner roll with 1 tsp. margarine; 8 oz. low-fat milk Total cal. = 895 Snack: 1/2 c. sherbet; 1 granola cookie Total cal. = 185 Suggested Readings 1. Ray TR, Fowler R. Current issues in sports nutrition in athletes. South Med J. 2004;97(9):863–866. 2. Wheeler KB, Cameron AM. Sports nutrition: the pre-event meal. American Rowing pp. 30–32, January/February 1989. 34 E. Trowers TABLE 3.4. High-carbohydrate sample meal plan. Breakfast: 3/4 c. orange or pineapple juice; 1 egg, fried; 2 slices toast with 2 tsp. margarine and 2 tsp. jelly; 3/4 c. cereal; 8 oz. skim or low-fat milk or hot cocoa Lunch: 1 or 2 sandwiches, each with 1 oz. meat or 1 oz. cheese or 2 Tbsp. peanut butter; carrot and celery sticks; 1 banana; 8 oz. skim or low-fat milk Dinner: 5 to 6 oz. baked fish or chicken without skin; 1 baked potato with 1 tsp. margarine; 1/2 c. green beans; 1/2 c. coleslaw; 2 pieces cornbread with 2 tsp. margarine and 2 tsp. honey; 1/2 c. sliced peaches; 8 oz. skim or low-fat milk Snack: 1 or 2 servings of fruit; 1 or 2 servings of cookies/crackers 4 Altitude, Heat, and Cold Problems EDWARD J. SHAHADY Patients may choose to be physically active in environments that can create illness, like high and low attitudes and the extremes of heat and cold. The primary care clinician needs to be aware of how to prevent and treat problems that are associated with these environments. Age, comorbid disease, and use of certain medications increase risk of environmental illness in some patients. A good working knowledge of the physiological responses to changes in altitude and temperature, clinical symptoms, and principles of treatment and prevention will facilitate effective management of this group of patients. Table 4.1 lists some of the problems that are encountered by the primary care clinician. 1. High-Altitude Sickness 1.1. Acute Mountain Sickness Thirty-four million people travel yearly to high altitudes for some type of recreational activity. Heights above 5000 ft usually produce some mild symptoms of shortness of breath and mild headache for a few days. Individuals with compromised pulmonary function, the elderly, and those with other chronic diseases may experience more severe symptoms and symptoms at less elevation. Twenty-five percent of those who travel above 8500 ft experience symptoms of high-altitude illness and one in 100 develop serious symptoms. The syndrome of high-altitude illness represents a spectrum of clinical conditions that range in severity from mild acute mountain sickness (AMS) with an unpleasant constellation of symptoms to the life-threatening conditions of high-altitude pulmonary edema (HAPE) and high-altitude cerebral edema (HACE). Acute mountain sickness may also be the early presentation of a process that can progress to life-threatening HAPE or HACE. Although most primary care clinicians practice in areas below 5000 ft they still will encounter altitude sickness. Patients will rely on primary care clinicians for advice on prevention of altitude illness and if they become ill the telephone and the Internet bring patients and clinicians together no matter what the distance. 35 The symptoms of mild AMS are similar to a viral syndrome, a hangover, or physical exhaustion. These vague symptoms have led to misdiagnosis in some cases. In a setting of high-altitude exposure, these vague symptoms should be considered AMS until proven otherwise. The diagnosis of AMS can be made when a patient has had a recent exposure to increase in altitude for several hours and complains of a headache plus at least one of the following symptoms: nausea, vomiting, loss of appetite, fatigue, dizziness, light-headedness, and difficulty in sleeping. The headache may be mild but is usually bitemporal and throbbing in nature. The other symptoms described may range in severity from mild to incapacitating. Acute mountain sickness symptoms usually develop within a few hours after arrival at high altitude and reach maximum intensity in 24 to 48 h. Most individuals become symptom-free by the third or fourth day. The onset of symptoms may be delayed in some individuals for up to 4 days and a few may have symptoms that may be prolonged for up to 1 month. Most people tolerate or treat their symptoms by remaining at the same altitude until the illness resolves. Acute mountain sickness is rare below 8000 ft and is more common with rapid ascent to altitudes greater than 10,000 ft. Difficulty with breathing on exertion is common at high altitudes but if the difficulty is present at rest, HAPE may be present. Similarly, any alteration in mentation or signs of ataxia suggests the presence of HACE. Any hint of HAPE or HACE should be taken seriously. 36 E.J. Shahady TABLE 4.1. Classification of environmental problems. High-altitude illness ● Acute mountain sickness ● High-altitude pulmonary edema ● High-altitude cerebral edema ● Other altitude-related disorders: retinopathy, peripheral edema, venous stasis ● Chronic diseases and altitude Low-altitude illness ● Barotrauma to ears, sinuses, teeth, skin ● The bends Heat injury ● Heat cramps ● Heat exhaustion (heat syncope) ● Heatstroke Cold injury ● Hypothermia—mild, moderate, severe ● Frostbite ● Chilblains 1.1.1. Treatment The mild forms of AMS may not require specific treatment. It usually resolves spontaneously if further ascent and exercise are avoided. Halting ascent or activity to allow further acclimatization may reverse the symptoms; however, continuing the ascent exacerbates the underlying pathologic processes and may lead to disastrous results. Further treatment is indicated if the symptoms become severe enough to interfere with the individual’s activities. Acetazolamide (Diamox) speeds the process of acclimatization and, if given early in the illness, leads to a more rapid resolution of symptoms. A dose of 250 mg of acetazolamide given at the onset of symptoms and repeated twice daily is effective therapy. If AMS does not respond to maintenance of altitude, rest, and pharmacologic intervention within 24 h, the patient should descend to a lower altitude. A descent of 1500 to 3000 ft effectively reverses high- altitude illness in most cases. Oxygen, if available, addresses the primary insult of high-altitude exposure, corrects hypoxemia, and relieves the headache. For persistent difficulty in sleeping, it can be given in small amounts (1 to 2 L/min) during sleep. Insomnia generally results from periodic breathing, which is experienced by most visitors to altitude. This is best treated with the respiratory stimulant acetazolamide. Doses of acetazolamide as low as 62.5 mg at bedtime may be adequate to prevent periodic breathing and eradicate insomnia. Avoid the use of benzodiazepines and other sedative hypnotics because of their tendency to decrease ventilation during sleep. Dexamethasone is an effective treatment for AMS. It is usually used for patients who cannot tolerate acetazolamide, or in more advanced cases of AMS. Trials have used 8 mg initially, followed by 4 mg every 6 h. 1.1.2. Prevention The symptoms of AMS can be unpleasant enough to interfere or interrupt travel, business, or vacation plans. The majority of individuals with AMS report a decrease in activity. Allowing adequate time for acclimatization by slow ascent is the best method of prevention. This may not be possible for a short vacation period. The altitude where the individual sleeps is the key altitude. The ideal first-night altitude is no higher than 8000 ft, with a subse- quent increase of not more than 2000 ft each night. If the journey begins at 10,000 ft, then three nights should be spent acclimatizing. Daytime excur- sions to higher altitudes with a return to a lower sleeping altitude are accept- able. Mild to moderate exercise aids acclimatization but overexertion may contribute to AMS. Intake of a high-carbohydrate diet and maintenance of adequate hydration are helpful. Acetazolamide (Diamox) is very effective in preventing AMS. Lower dosages provide similar prophylaxis with fewer adverse reactions than higher dosages. The current recommended dosage is 125 mg twice daily starting 24 h before ascent and continuing for the first 2 days at high altitude. The dosage for 4. Altitude, Heat, and Cold Problems 37 children is 2.5 mg/kg/dose up to 125 mg total, given twice daily. Acetazolamide is a carbonic anhydrase inhibitor that induces a mild diuresis and stimulates respiration. This respiratory stimulation is particularly important during sleep, when the hypoxemia caused by periodic breathing is eradicated by acetazolamide. The diuretic effects reduce fluid retention in AMS. This drug also low- ers cerebrospinal fluid (CSF) volume and pressure, which may play an additional role in prevention and treatment of cerebral edema. The most common adverse reactions to acetazolamide include paresthesias and polyuria. Less common reactions include nausea, drowsiness, tinnitus, and transient myopia. The flavor of carbonated beverages such as soft drinks or beer may change. Acetazolamide is a sulfa drug, so patients allergic to sulfa drugs may have a reaction. Dexamethasone can prevent AMS but should be reserved for individuals who cannot tolerate acetazolamide. The lowest effective dosage is 4 mg every 12 h. Other issues that aid with prevention include carbohydrate ingestion and avoiding alcohol and smoking. Some but not all studies suggest carbohydrates as the most efficient form of fuel for digestion. This fuel consumes less oxygen and may leave more oxygen available for other bodily activities. Avoidance of alcohol and smoking optimizes acclimatization. Alcohol depresses respiration and produces dehydration. Smoking cigarettes decreases oxygen-carrying capacity. 1.2. High-Altitude Pulmonary Edema HAPE is the most common fatal manifestation of severe high-altitude illness. It is uncommon below 10,000 ft but can occur at 8000 ft related to heavy exercise. At higher altitudes, it may also occur at rest or with light activity. The symptoms may start a few hours after reaching the higher altitude but usually begin slowly 2 to 4 days after arrival at high altitude. Dyspnea on exertion, fatigue with min- imal to moderate effort, and dry cough are early manifestations of the disease. These symptoms may be subtle but noticeable when comparing the victim with others in the group. The symptoms of AMS are also usually present. As HAPE progresses the dyspnea intensifies with effort and is unrelieved by rest. The cough becomes productive of copious amounts of clear watery sputum, and with time, hemoptysis. This may be followed by ataxia and altered mentation secondary to hypoxemia and/or cerebral edema. Examination reveals an increased respiratory and heart rate, with audible rhonchi and gurgles. 1.2.1. Treatment Descent to a lower altitude, bed rest, and supplemental oxygen are the most effective methods of therapy. Descents of 1500 to 3000 ft should be adequate to allow for a rapid recovery. After recovery, the victim may be able to reas- cend in 2 or 3 days. Mild cases may be treated without descent and 1 or 2 days of bed rest. The rate of improvement is increased with oxygen. At ski resorts, victims of mild HAPE are given oxygen in their hotel rooms and are able to 38 E.J. Shahady recover, avoid descent, and continue their ski holidays. Any treatment plan that does not include descent mandates serial examinations of the patient by clinicians with experience in managing high-altitude illness. For a discussion of treatment for more severe pulmonary edema, consult the readings suggested at the end of this chapter. 1.2.2. Prevention Nifedipine, 20 mg three times daily, taken before ascent and continued at altitude for 3 days is effective in preventing a recurrence of HAPE. Acetazolamide may be useful in the prevention in susceptible individuals because of respiratory stimulation caused by acetazolamide. Avoiding extreme exertion during the first 2 days at altitude also helps in individuals with a prior history of HAPE. Gradual ascent that allows time to acclimatize and immediate cessa- tion of further ascent at the onset of symptoms are the most effective means of prevention. 1.3. High-Altitude Cerebral Edema HACE is not as common as HAPE but is a most severe form of high-altitude illness. Most cases occur above 12,000 ft. The usual time course is 1 to 3 days for the development of severe symptoms. HACE has developed in as little as 12 h or as long as 5 to 9 days following AMS. The symptoms of HACE usually include those of AMS and HAPE. Headaches, fatigue, vomiting, cough, and dyspnea are present along with the symptoms of HACE, which include ataxia, slurred speech, and altered mentation. The mental changes can range from mild emotional lability or confusion to hallucinations, and decreased levels of consciousness. Ataxia is the most sensitive early indica- tor of cerebral edema because of the sensitivity of the cerebellum to decreased oxygen. The appearance of ataxia alone is an indication for immediate descent. Early recognition and initiation of descent are the keys to suc- cessful therapy of HACE. Long-term neurologic deficits, such as ataxia and cognitive impairment, are possible after recovery from an episode of HACE. For a complete discussion of treating HACE, consult the readings suggested at the end of this chapter. Prevention is the same as that discussed with HAPE and AMS. 1.4. Other Altitude-Related Disorders High-altitude retinal hemorrhage can occur with high altitude and high-altitude illness. These hemorrhages usually occur at altitudes over 17,500 ft. They also occur at lower levels when strenuous activity is involved or the patient has suffered from HAPE or HACE. The hemorrhages are usually asymptomatic, only discovered with retinal examination, and resolve without treatment in 2 to 3 weeks. Occasionally, the macular region is involved and 4. Altitude, Heat, and Cold Problems 39 [...]... extension blow to the superior aspect of the shoulder may rupture the AC ligament and produce an AC joint separation The movements that recreate the pain help pinpoint the anatomic structures involved in the injury Abducting the arm to 90° impinges the supraspinatus muscle under the corocoacromial ligament In addition, pain produced with this movement indicates the presence of the rotator cuff impingement syndrome... Medicine for Coaches and Trainers Chapel Hill, NC: University of North Carolina Press; 1991: 52, with permission.) AC separation can be graded by the amount of trauma that occurs to the joint and the acromioclavicular and coricoclavicular ligaments There are five grades of injury but in the primary care office setting only three grades of injury are usually seen In the emergency room setting a grade 5 injury... leads the nation in the incidence of these injuries Many patients may not develop symptoms for 24 to 48 h after their dive experience and others may suffer symptoms that they may not associate with the dive experience Primary care clinicians, no matter their location, will need to know the principles of prevention and recognition of the symptoms associated with low-altitude illness 2. 1.1 Gas Principles... used The statement “clavicle fractures will heal as long as the two ends are in the same room” is often made to indicate how unusual it is for them not to heal The break is usually at the middle third of the clavicle where the curvature changes This is the weakest part of the bone The racture interrupts weight transmission from the arm to the axial skeleton The resulting deformity is produced by the. .. Fractures of the distal 1/3 of the clavicle are not as stable and may require a special brace to provide stability If the AC joint is involved AC joint arthritis may occur in the future The vast majority of clavicle fractures are located in the midshaft They heal very well with a sling that supports the arm and adequate pain control The figure of eight-clavicle strap that was popular in the past is... Hypothermia and localized cold injuries Emerg Med Clin N Am 20 04 ;22 :28 1– 29 8 Suggested Readings Biem J, Koehncke N, Classen D, Dosman J Out of the cold: management of hypothermia and frostbite CMAJ 20 03;168(3) Gallagher SA, Hackett PH High altitude illness Emerg Med Clin N Am 20 04 ;22 : 329 –355 Kuo DC, Jerrard DA Environmental insults: smoke inhalation, submersion, diving, and high altitude Emerg Med Clin... then to skin mottling Cutis marmorata commonly involves the trunk and torso Type II DCS symptoms can also involve the central nervous system (CNS), the inner ear, and the lungs The spinal cord, especially the upper lumbar area, is more often involved than the cerebral tissue Symptoms include limb weakness or paralysis, paresthesias, numbness, and low back and abdominal pain Limb symptoms often begin... injury The fingers, toes, ears, nose, and penis are most susceptible to cold injury The injury results in both freezing and nonfreezing syndromes Frostbite is the most common freezing injury Exposure to wet cold causes trench foot and immersion foot, which are nonfreezing injuries Dry cold causes a nonfreezing injury called chilblains (pernio) The symptoms of cold injury reflect the severity of the exposure... cramping is often present The skin remains erythematous, dry, and very painful to touch, after rewarming Bullae commonly develop Protracted symptoms of pain during weight bearing, cold sensitivity, and hyperhidrosis often last for years Prevention of trench foot often just requires continual wearing of dry socks Frostbite can be classified into degrees Lack of feeling and redness are characteristic of. .. gases will occupy more volume [1] Think of the impact this will have on the areas of the body with gas-filled spaces like the ears, sinuses, teeth, and lungs Henry’s law states that gas enters a given volume of liquid in proportion to the partial pressure of the gas Nitrogen, like other gases during descent, becomes increasingly soluble in blood and tissue During ascent, the same gases become less soluble . gain weight by eating large quantities of fatty and other non- nutritious foods. The main goal of weight gain in the athlete is to increase muscle mass. This is best achieved by an increase in. occur more frequently in the obese. Stretch marks and thinning of the skin also occur more often in obese persons. The approach to helping the obese patient involves a several-pronged attack plan monitoring because high-altitude travel produces a mild increase in BP secondary to increased catecholamine activity. The increase begins in the first few days and reaches maximum in 2 to 3 weeks. The

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